Summary THA Revision is most commonly performed to address aseptic loosening, fracture, instability, or infection associated with a prior THA. Diagnosis and etiology of THA failure can be determined by a combination of physical examination, labs, and hip radiographs. Treatment depends on etiology of failure, prior surgery and patient activity demands. Epidemiology Incidence in the United States is projected to increase >100% by 2030 Demographics roughly equal male to female average age of roughly 65-70 in most studies Most common causes for revision: overall and after 2 years post-operatively mechanical failure early failure (< 2 years post-operatively) infection periprosthetic fracture Etiology Pathophysiology femoral component failure acetabular component failure both component failure neither Indications wound healing complications periprosthetic fracture implant fracture hip instability periprosthetic joint infection (PJI) adverse local soft tissue reaction (MoM) trunnionosis osteolysis aseptic loosening limb length discrepancy (LLD) Broad categories revision surgery without affecting modular OR nonmodular components revision wound closure psoas release heterotopic bone excision ORIF of periprosthetic fracture revision surgery affecting modular components only femoral head and or polyethyelene exchange titanium sleeve revision surgery nonmodular components acetabular component exchange login to view 1 more bullet femoral component exchange removal of both components login to view 3 more bullets Classification of Bone Loss Acetabulum AAOS Classification of Acetabular Bone Loss Type I (segmental) Loss of part of the acetabular rim or medial wall Type II (cavitary) Volumetric loss in the bony substance of the acetabular cavity Type III (combined deficiency) Combination of segmental bone loss and cavitary deficiency Type IV (pelvic discontinuity) Complete separation between the superior and inferior acetabulum Type V (arthrodesis) Arthrodesis Paprosky Classification of Acetabular Bone Loss Type I Minimal deformity, intact rim Type IIA Superior bone lysis with intact superior rim Type IIB Absent superior rim, superolateral migration Type IIC Localized destruction of medial wall Type IIIA Bone loss from 10am-2pm around rim, superolateral cup migration Type IIIB Bone loss from 9am-5pm around rim, superomedial cup migration Femur AAOS Classification of Femoral Bone Loss Type I (segmental) Loss of bone of the supporting shell of femur Type II (cavitary) Loss of endosteal bone with intact cortical shell Type III (combined) Combination of segmental bone loss and cavitary deficiency Type IV (malalignment) Loss of normal femoral geometry due to prior surgery, trauma, or disease Type V (stenosis) Obliteration of the canal due to trauma, fixation devices, or bony hypertrophy Type VI (femoral discontinuity) Loss of femoral integrity from fracture or nonunion Paprosky Classification of Femoral Bone Loss Type I Minimal metaphyseal bone loss Type II Extensive metaphyseal bone loss with intact diaphysis Type IIIA Extensive metadiaphyseal bone loss, minimum of 4 cm of intact cortical bone in the diaphysis Type IIIB Extensive metadiaphyseal bone loss, less than 4 cm of intact cortical bone in the diaphysis Type IV Extensive metadiaphyseal bone loss and a nonsupportive diaphysis Presentation Symptoms groin pain --> acetabulum thigh pain --> femoral stem start-up pain --> component loosening night pain --> infection no improvement in pain after surgery --> incorrect diagnosis Physical exam inspection assess wound for infection gait external rotation of the affected extremity login to view 2 more bullets range of motion in flexion, extension, abduction looking for restriction of motion or pain login to view 1 more bullet provocative test pain with resisted hip flexion suggests psoas impingement Imaging Radiographs recommended views AP pelvis orthogonal views of involved hip full-length femur radiographs opitional views pre-operative radiographs immediate post-operative radiographs Judet views login to view 1 more bullet CT scan indications useful for determining extent of osteolysis login to view 1 more bullet angiogram to determine relationship to neurovascular structures with Paprosky IIIB defects assessment of component position Studies Serum labs infectious laboratories ESR CRP CBC metal levels cobalt and chromium levels login to view 2 more bullets Aspiration recommended if infectious laboratories are suggestive of infection Treatment Nonoperative indications differing etiology of pain (i.e. back pain, greater trochanteric bursitis, etc.) no identifiable etiology of pain Operative Femoral revision primary total hip arthroplasty components login to view 2 more bullets uncemented extensively porous-coated long-stem prosthesis (or porous-coated/grit blasted combination) or modular tapered stems login to view 4 more bullets femoral impaction bone grafting login to view 5 more bullets allograft prosthetic composite (APC) login to view 2 more bullets endoprosthetic replacement (EPR) login to view 3 more bullets cemented stems login to view 6 more bullets Acetabular revision porous-coated hemisphere cup or jumbo secured with screws login to view 5 more bullets porous-coated hemispherical cup with acetabular augments login to view 6 more bullets reconstruction cage with structural bone allograft login to view 5 more bullets custom triflange cup login to view 2 more bullets cemented acetabular components login to view 1 more bullet liner options login to view 1 more bullet Combined revision femoral head and polyethylene exchange login to view 6 more bullets conversion from a hip arthrodesis login to view 6 more bullets Revision without changed modular or nonmodular components ORIF periprosthetic fracture login to view 2 more bullets psoas release login to view 3 more bullets heterotopic bone excisions login to view 2 more bullets Surgical Techniques Femoral revision primary total hip arthroplasty components technique login to view 1 more bullet uncemented extensively porous-coated long-stem prosthesis or modular tapered stems technique login to view 6 more bullets femoral impaction bone grafting technique login to view 2 more bullets allograft prosthetic composite (APC) technique login to view 5 more bullets endoprosthetic reconstruction (EPR) technique login to view 2 more bullets cemented stems technique login to view 3 more bullets Acetabular revision porous-coated hemisphere cup or jumbo secured with screws technique login to view 6 more bullets porous-coated hemispherical cup with acetabular augments technique login to view 5 more bullets reconstruction cage and structural bone allograft technique login to view 2 more bullets custom triflange technique login to view 5 more bullets cemented cup technique login to view 1 more bullet Combined revision Femoral head and polyethylene exchange technique login to view 2 more bullets Conversion from hip arthrodesis technique login to view 5 more bullets Revision without changed modular or nonmodular components ORIF periprosthetic fracture technique login to view 2 more bullets psoas release technique login to view 1 more bullet heterotopic bone (HO) excision technique login to view 2 more bullets Prognosis Lower mid-term and long term survival compared to primary THA with higher rates of complications dislocation (even in simple procedures) infection nerve palsy fractures abductor deficiency DVT limb length discrepancy